Radiotherapy for breast cancer: today and tomorrow

Breast conservation therapy (BCT) with lumpectomy and radiation has allowed many women to preserve their breasts and avoid disfiguring surgery. Lumpectomy and breast irradiation is a standard therapy for early breast cancer patients who desire breast conservation. However, the overall rate of mastectomy exceeds that of BCT in the United States. There have been significant advances in patient awareness of the options available for local management of early breast cancer and changes in the attitudes of physicians, including surgeons, allowing a gradual rise in the rate of BCT in the last two decades. Now, investigations are designed to define subgroups of patients with early breast cancer in whom radiation can be safely omitted. In locally advanced breast cancer, neoadjuvant chemotherapy has allowed some women to have BCT after initial cytoreduction. This approach results in excellent local control when patients are carefully selected for BCT. There is renewed interest in postmastectomy radiation for early breast cancer patients with 1 to 3 positive lymph nodes. In this intermediate risk group for locoregional recurrence, the addition of chest wall and regional lymphatic irradiation to adjuvant systemic therapy has potential for significant improvement in ultimate survival. This concept is novel in breast cancer, a disease that was believed to be systemic at inception and in which only systemic control was thought to impact survival. In this era of effective adjuvant systemic therapy for breast cancer, local control measures have become more important as local control has real potential for impacting survival.